Week 1 REPAIR

PERIOPERATIVE NURSING -Restoration of diseased or damaged tissues

naturally, by healing processes, or artificially, as
-Used to describe the nursing care provided in by surgical means.
the total surgical experience of the patient,
which spans the entire surgical experience, -Multiple wound repair
consists of three phases that begin and end at
particular points in the sequence of surgical Reconstructive or Cosmetic
experience events. -Reconstructive plastic surgery generally
a. Preoperative phase involves treatment of conditions that have
caused an abnormal change in body shape or
b. Intraoperative phase appearance.
c. Post-operative phase Mammoplasty Plastic
Preoperative Phase -surgery of the breast to alter its shape, size, or
position
-Begins when the decision to proceed with
surgical intervention is made and ends with the Facelift
transfer of the patient onto the operating room
-also known as rhytidectomy , is a surgical
(OR) bed.
procedure that lifts and tightens these facial
Intraoperative Phase tissues.
-Begins when the patient is transferred onto the Palliative
OR bed and ends with admission to the PACU
(to relieve pain or correct a problem such as
(Post anesthesia unit).
debulking a tumor to achieve comfort, or
*Begin @ OR Bed removal of a dysfunctional gallbladder).
*End @ PACU Debulking
Intraoperative nursing responsibilities involve -is the reduction of as much of the bulk
acting as; (volume) of a tumour without the intention of a
 scrub nurse, complete eradication.
 circulating nurse, or Rehabilitative
 registered nurse first assistant
-Is the post-surgical program of re-establishing
Postoperative Phase
joint motion, muscle strength around the joint
-Begins with the admission of the patient to the and finally joint function
PACU and ends with a follow up evaluation in
the clinical setting or home. -total joint replacement surgery to correct
crippling pain or progression of degenerative
SURIGICAL CLASSIFICATIONS osteoarthritis
Based on;
 Diagnosis
 Cure
 Repair
 Reconstructive or cosmetic
 Palliative
 Rehabilitative
DIAGNOSIS
 Biopsy
 Exploratory
 laparotomy
 laparoscopy
CURE
-excision of a tumor or an inflamed appendix
According to DEGREE OF RISK PREOPERATIVE PHASE
MajorSurgery
-High risk / Greater Risk forInfection
-Extensive
-Prolonged
-Large amount of bloodloss
-Vital organ may be handled or removed
MinorSurgery
-Generally notprolonged
-Leads to few seriouscomplication
-Involves less risk
Special Considerations During the
PerioperativePeriod
-if the surgical patient is currently using beta-
blockers, particular attention is given to ensure
timely administration of the beta-blocker and
appropriate monitoring of vital signs.

-If the patient has not taken the usual dosage of

this medication, the anesthesiologist or certified
registered nurse anesthetist (CRNA) must
evaluate whether or not it should be
administered prior to surgery or during the
perioperativeperiod.

-The nurse in the perioperative area needs to be Bariatric Patients

alert for appropriate preoperative prescriptions -is a specialty that revolves around diagnosing,
aimed at preventing VTE (venous treating, and managing patients who are obese.
thromboembolism) and SSI (surgical site -Obesity increases the risk and severity of
infections). complications associated with surgery.
Gerontologic Considerations -The patient with obesity tends to have shallow
-older adult patients have less physiologic respirations when supine, increasing the risk of
reserve (i.e., the ability of an organ to return to hypoventilation and postoperative pulmonary
normal after a disturbance in its equilibrium) complications.

-Respiratory and cardiac complications are the

leading causes of postoperative morbidity and
mortality in older adults

-Cardiac reserves are lower, renal and hepatic

functions are depressed, and gastrointestinal
activity is likely to be reduced

Critical factors for Older patients;

(1) skillful preoperative assessment and

treatment

(2) proficient anesthesia and surgical care, and

(3) meticulous and competent postoperative

and postanesthesiamanagement.
 -Less opportunity to assess for
latepostoperative complication.

Patients Undergoing Emergency Surgery

-Physical characteristics found in patients who
are obese impede intubation, such as short -Emergency surgeries are unplanned and occur
thick necks, large tongues, recessed chins, and with little time for preparation of the patient or
redundant pharyngeal tissue. the perioperativeteam.

The preoperative assessment -The patient, who may have undergone

traumatic experience, may need extra support
-looks for these characteristics as well as the
and explanation of the surgery.
presence of obstructive sleep apnea, frequently
diagnosed in patients who are obese. -For the unconscious patient, informed consent
and essential information, such as pertinent
-Sleep apnea is treated with continuous
past medical history and allergies, need to be
positive airway pressure (CPAP).
obtained from a family member, if one is
-The use of CPAPshould be incorporated available.
throughout the perioperativeperiod
Informed Consent
Patients With Disabilities
-is the patient’s autonomous decision about
-People who are hearing impaired may need whether to undergo a surgical procedure.
and are entitled by law to a sign interpreter or
Voluntary and written informed consent from
some alternative communication system
the patient is necessary before
perioperatively.
nonemergentsurgery can be performed to
-If the patient relies on signing or speech (lip) protect the patient from unsanctioned surgery
reading and their eyeglasses or contact lenses and protect the surgeon from claims of an
are removed or the health care staff wears unauthorized operation or battery.
surgical masks, an alternative method of
Surgeon’s responsibility
communication will be needed.
 provide a clear and simple explanation
-Patients with respiratory problems related to a
of what the surgery will entail prior to
disability (e.g., multiple sclerosis, muscular
the patient giving consent.
dystrophy) may experience difficulties unless
 inform the patient of the benefits,
the problems are made known to the
 alternatives,
anesthesiologistor CRNAand adjustments are
 possible risks,
made.
 complications,
Patients Undergoing Ambulatory Surgery  disfigurement,
 disability, and
Ambulatory Surgery/ Same-day Surgery /  removal of body parts
Outpatient Surgeryor short-stay surgery not  as well as what to expect in the early
requiring admission for an overnight hospital and late postoperative periods.
stay but may entail observation in a hospital
setting for 23 hours or less. Nurse Responsibility

Advantages:  Clarifies the information provided,

 And If the patient requests additional
-Reduces length of hospital stay and cutscosts information, the nurse notifies the
-Reduces stress for thepatient physician.
 The nurse ascertains that the consent
-Less incidence of hospital acquiredinfection form has been signed before
-Less time lost from work by the patient; administering psychoactive
minimal disruptions on the patient’s activities premedication , because consent is not
and familylife. valid if it is obtained while the patient is
under the influence of medications that
Disadvantages: can affect judgment and decision
making capacity.
-Less time to assess the patient and perform
preoperative teaching.

-Less time to establishrapport

Informed consent is necessary in the following
circumstances:

 Invasive procedures, such as a surgical

incision, a biopsy, a cystoscopy, or
paracentesis
 Procedures requiring sedation and/or
anesthesia
 A nonsurgical procedure, such as an
arteriography, that carries more than a
slight risk to the patient
 Procedures involving radiation Preoperative Assessment
 Blood product administration
GOAL OF PREOPERATIVE PERIOD;
-The patient personally signs the consent if of
 The goal in the preoperative period is
legal age and mentally capable.
for the patient to be as healthy as
-Permission is otherwise obtained from a possible.
surrogate, who most often is a responsible  Every attempt is made to assess for and
family member (preferably next of kin) or legal address risk factors that may contribute
guardian. to postoperative complications and
delay recovery
-In an emergency, it may be necessary for the
 a health history is obtained,
surgeon to operate as a lifesaving measure
 aphysical examination is performed
without the patient’s informed consent.
 vital signs are noted, and a baseline is
-However, every effort must be made to contact established for future comparisons
the patient’s family. In such a situation, contact  Asking for Allergies
can be made by telephone, fax, or other  Use of over the counter medications,
electronic means and consent obtained. including herbal; and other
supplements
-If the patient has doubts and has not had the
opportunity to investigate alternative Routine Preoperative Screening Test
treatments, a second opinion may be
Nutritional and Fluid Status
requested.
-Optimal nutrition is an essential factor in
-No patient should be urged or coerced to give
promoting healing and resisting infection and
informed consent.
other surgical complications.
-Refusing to undergo a surgical procedure is a
-Assessment of a patient’s nutritional status;
person’s legal right and privilege.
obesity, weight loss, malnutrition, deficiencies
-Consent forms should be written in easily in specific nutrients, metabolic abnormalities,
understandable words and concepts to and the effects of medications on nutrition.
facilitate the consent process and should use
-Nutritional needs may be determined by
other strategies and resources as needed to
measurement of body mass index and waist
help the patient understand the content.
circumference.
-Asking patients to describe in their own words
-Any nutritional deficiency should be corrected
the surgery they are about to have promotes
before surgeryto provide adequate protein for
nurses’ understanding of patients’
tissue repair.
comprehension.
-Assessment of a patient’s hydration status is
also essential.

-Dehydration, hypovolemia, and electrolyte

imbalances can lead to significant problems in
patients with comorbidmedical conditions or in
older adults
DENTITION

The condition of the mouth is an important Hepatic and Renal Function

health factor to assess.
-The presurgicalgoal is optimal function of the
Dental caries, dentures, and partial plates are liver and urinary systems so that medications,
particularly significant to the anesthesiologist or anesthetic agents, body wastes, and toxins are
CRNA, because decayed teeth or dental adequately metabolized and removed from the
prostheses may become dislodged during body.
intubation and occlude the airway.
-The liver, lungs, and kidneys are the routes for
Drug or Alcohol Use elimination of drugs and toxins.

Ingesting even moderate amounts of alcohol -The liver is important in the biotransformation
prior to surgery can weaken a patient’s of anesthetic compounds.
immune system and increase the likelihood of
-Disorders of the liver may substantially affect
developing postoperative complications.
how anesthetic agents are metabolized.
In an emergency, to prevent vomiting and
-Acute liver disease is associated with high
potential aspiration, a nasogastrictube is
surgical mortality; preoperative improvement in
inserted before general anesthesia is given.
liver function is a goal.
NURSE RESPONSIBILITY
-The kidneys are involved in excreting
-People who have a substance abuse problem anesthetic medications and their metabolites;
may deny or attempt to hide it. In such therefore, surgery is contraindicated if a
situations. patient has acute nephritis, acute renal
insufficiency with oliguriaor anuria, or other
-The nurse who is obtaining the patient’s health
acute renal problems
history needs to ask frank questions with
patience, care, and a nonjudgmental attitude. Endocrine Function

-Such questions should include asking whether -The patient with diabeteswho is undergoing
the patient has had two drinks per day or more surgery is at risk for both hypoglycemiaand
on a regular basis in the 2 weeks prior to hyperglycemia.
surgery.
-Hypoglycemiamay develop during anesthesia
Respiratory Status or postoperatively from inadequate
carbohydrates or excessive administration of
The patient is educated about breathing
insulin.
exercises and the use of an incentive
spirometer, if indicated, to achieve optimal -Hyperglycemia, can increase the risk of surgical
respiratory function prior to surgery. wound infection, may result from the stress of
surgery, which can trigger increased levels of
Patients who smoke are urged to stop 30 days
catecholamine.
before surgery to significantly reduce
pulmonary and wound healing complications. -strict glycemiccontrol(80 to 110 mg/dL) leads
to better outcomes.
Patients who smoke are more likely to
experience poor wound healing, a higher NURSE RESPONSIBILITY
incidence of SSI, and complications that include
Frequent monitoring of blood glucose levels is
VTE and pneumonia.
important before, during, and after surgery.
Cardiovascular Status
Patients who have received corticosteroidsare
-If the patient has uncontrolled hypertension, at risk for adrenal insufficiency.
surgery may be postponed until the blood
The use of corticosteroids for any purpose
pressure is under control.
during the preceding year must be reported to
-Surgical treatment can be modified to meet the the anesthesiologist or CRNA and surgeon.
cardiac tolerance of the patient.
 A.Garlic

B.Ginkgo biloba,

C.Ginseng,

D.Kava kava

E.St. John’s wort

F.Licorice extract

G.Valerian

Psychosocial Factors

The nurse anticipates that most patients have

emotional reactions prior to surgery—obvious
The patient is monitored for signs of adrenal
or veiled, normal or abnormal.
insufficiency
Fear may be related to;

the unknown,

lack of control,

death may be influenced by anesthesia, pain,

complications, cancer, or prior surgical
experience.

Manifestation of Fears

-anxiousness

-bewilderment
Patients with uncontrolled thyroid disorders are -anger
at risk for thyrotoxicosis(with hyperthyroid
disorders) or respiratory failure(with -tendency toexaggerate
hypothyroid disorders). -sad, evasive, tearful,clinging
The patient with an associated history of a -inability toconcentrate
thyroid disorder is assessed preoperatively.
-short attentionspan

-failure to carry out simpledirections

-dazed

Nursing Intervention to MinimizeAnxiety

ｷ Explore client’sfeeling

ｷ Allow client’s to speak openly about

fears/concern.

ｷ Give accurate information regardingsurgery

Immune Function
(brief, direct to the point and in simpleterms)
-An important function of the preoperative
assessment is to determine the presence of ｷ Give empatheticsupport
infection or allergies.
ｷ Consider the person’s religious preference
-Routine laboratory tests used to detect and arrange forvisitbya priest / minister
infection include the white blood count (WBC) asdesired.
and the urinalysis.
Spiritual and Cultural Beliefs
-Surgery may be postponed in the presence of
infection. -Spiritual beliefs play an important role in how
people cope with fear and anxiety.
Commonly used herbal medications may
include -Regardless of the patient’s religious affiliation,
adhering to spiritual beliefs can be therapeutic.
-Showing respect for a patient’s cultural values If the patient does not cough effectively,
and beliefs facilitates rapport and trust. atelectasis(collapse of the alveoli), pneumonia,
or other lung complications may occur.
Preoperative Nursing Interventions

Providing Patient Education

initiated as soon as possible,

Mobility and Active Body Movement
-beginning in the physician’s office,
The goals of promoting mobility postoperatively
-in the clinic, or
are to;
-at the time of PAT (pre-admission testing)
improve circulation,
when diagnostic tests are performed.
prevent venous stasis, and
Instruction is spaced over a period of time to
allow the patient to assimilate information and promote optimal respiratory function.
ask questions as they arise.
Patient should be taught that early and
Deep Breathing, Coughing, and Incentive frequent ambulation postoperatively, as
Spirometry tolerated, will help prevent complications.

One goal of preoperative nursing care is to Nurse responsibilities

educate the patient how to promote optimal
The nurse explains the rationale for frequent
lung expansion and resulting blood oxygenation
position changes after surgery and then shows
after anesthesia.
the patient how to turn from side to side and
The nurse then demonstrates how to take a how to assume the lateral position without
deep, slow breath and how to exhale slowly. causing pain or disrupting intravenous (IV) lines,
drainage tubes, or other equipment.
After practicing deep breathing several times,
-Exercise of the extremities includes
the patient is instructed to breathe deeply,
extensionand flexionof the knee and hip joints
exhale through the mouth, take a short breath,
(similar to bicycle riding while lying on the side)
and cough deeply in the lungs.
unless contraindicated by type of surgical
The nurse or respiratory therapist also procedure (e.g., hip replacement).
demonstrates how to use an incentive
At first, the patient is assisted and reminded to
spirometer, a device that provides
perform these exercises. Later, the patient is
measurement and feedback related to
encouraged to do them independently.
breathing
Muscle tone is maintained so that ambulation
Effectiveness
will be easier.
In addition to enhancing respiration, these
The nurse should remember to use proper body
exercises may help the patientrelax.
mechanics and to instruct the patient to do the
Coughing andSplinting same.

-If a thoracic or abdominal incision is Pain Management

anticipated, the nurse demonstrates how to
A pain assessment should include
splint the incision to minimize pressure and
differentiation between acute and chronic pain.
control pain.
A pain intensity scale should be introduced and
-The patient is informed that medications are
explained to the patient to promote more
available to relieve pain and should be taken
effective postoperative pain management.
regularly for pain relief so that effective deep-
breathing and coughing exercises can be Cognitive Coping Strategies
performed comfortably.
Cognitive strategies may be useful for relieving
The goal in promoting coughing is to mobilize tension, overcoming anxiety, decreasing fear,
secretions so and achieving relaxation.

that they can be removed. Deep breathing Strategies include;

before coughing stimulates the cough reflex.
 -To minimize respiratory tract secretion and
changes in heartrate.

-To relax the patient and reduceanxiety.

Nurse Responsibilites

-If a preanestheticmedication is given, the

patient is kept in bed with the side rails raised,
because the medication can cause
lightheadedness or drowsiness.
Preparing the Patient the Evening
BeforeSurgery -During this time, the nurse observes the
patient for any untoward reaction to the
Preparing theSkin
medications.
-have a full bath to reduce microorganisms in
-The immediate surroundings are kept quiet to
theskin.
promote relaxation, and some facilities use soft
-hair should be removed within 1-2 mm of the classical music
skin to avoid skin breakdown, use of electric
-The preoperative medication is prescribed “on
clipper ispreferable.
call to OR.”
Preparing the G.Itract

-NPO, cleansing enema asrequired

Maintaining the Preoperative Record
Preparing forAnesthesia
The nurse completes the preoperative checklist
-Avoidalcoholand
The completed medical record (with the
cigarettesmokingforatleast24hours
preoperative checklist and verification form)
beforesurgery.
accompanies the patient to the OR with the
Promoting rest andsleep surgical consent form attached, along with all
laboratory reports and nurses’ records.
-Administer sedatives asordered
Any unusual last-minute observations that may
have a bearing on anesthesia or surgery are
Preparing the Person on the Day OfSurgery noted prominently at the front of the medical
record.
Early A.MCare
Transporting the Patient to the PresurgicalArea
-Awaken 1 hour before preop medications
Morning bath, mouthwash -The patient is brought to the holding area or
presurgicalsuite about 30 to 60 minutes before
-Provide cleangown the anesthetic is to be given.
-Remove hairpins, braid long hair, cover hair -The patient is taken to the preoperative
with cap If available. holding area, greeted by name, and positioned
-Remove dentures, colored nail polish, hearing comfortably on the stretcher or bed.
aid,contact lenses,jewelries. -The surrounding area should be kept quiet if
-Take baseline vital sign before the preoperative medication is to have maximal
preopmedication. Check ID band, skinprep effect.

-Check for special orders –enema, IVline -Unpleasant sounds or conversation should be
avoided, because a sedated patient may
-CheckNPO misinterpret them.
-Have client void before preopmedication Transporting the Patient to theOR
Continue to support emotionally Accomplished
“preop carechecklist •Adheretotheprincipleofmaintainingthe
comfort and safety of thepatient.
PREOPERATIVEMEDICATIONS
•Accompany OR attendants to the patient’s
Goals: bedside for introduction and
properidentification.
-To aid in the administration of an anesthetics.
•Assist in transferring the patient from bed to
stretcher.

•Complete the chart and preoperativechecklist.

•Make sure that the patient arrive in the OR at

the propertime.

Patient’sFamily

-Direct to the proper waitingroom.

-Tell the family that the surgeon will probably

-contact them immediately after thesurgery.
INTRAOPERATIVE PHASE
-Explain reason for long interval of waiting:
anesthesia prep, skin prep, surgical
procedure,RR.

-Tell the family what to expect postop when

they see thepatient

Goals

ｷ Asepsis

ｷ Homeostasis

ｷ Safe Administration ofAnesthesia

ｷ Hemostasis

The Surgical Team

The surgical team consists of the;

-Patient,

-Anesthesiologist (physician)

-Certified registered nurse anesthetist (CRNA),

-Surgeon,

-Nurses,

-Surgical technicians,

-Registered nurse first assistants (rfnas)

-Certified surgical technologists (assistants).

Patient

-The patient is subject to several risks.

-Infection, failure of the surgery to relieve

symptoms or correct a deformity, temporary or
permanent complications related to the
procedure or the anesthetic agent, and death
are uncommon but potential outcomes of the
surgical experience.

Responsibilities

•Selects the anesthesia, administers it,

intubates the client if necessary, manages
technical problems related to the
administration of anesthetic agents, and
supervises the client’s condition throughout the
surgical procedure.

•A physician who specializes in the

administration and monitoring of anesthesia
while maintaining the overall well-being of
thepatient.

CRNA

A CRNA is a qualified and specifically trained

health care professional who administers
anesthetic agents, has graduated from an
accredited nurse anesthesia master’s program,
and has passed examinations sponsored by the
American Association of Nurse Anesthetists.